Nikiforchin Andrei, Sardi Armando, King Mary Caitlin, Iugai Sergei, Gushchin Vadim
Surgical Oncology, The Institute for Cancer Care, Mercy Medical Center, Baltimore, MD, USA.
Ann Surg Oncol. 2025 May 10. doi: 10.1245/s10434-025-17265-1.
Complete cytoreduction (CC) during cytoreductive surgery (CRS) is essential for favorable outcomes in appendix neoplasms. However, achieving CC is particularly challenging and may require non-trivial maneuvers when the tumor grows in the left retrohepatic space and along the ligamentum venosum (LV). MATERIALS AND METHODS: This multimedia article features a step-by-step video of CRS with left lateral liver lobectomy (LLLL) in a patient with a low-grade appendiceal mucinous neoplasm (LAMN) and extensive peritoneal dissemination. After initial systemic chemotherapy resulted in toxicity and no disease response, the patient sought CRS and hyperthermic intraperitoneal chemotherapy (HIPEC) at our center.
The preoperative PCI was 34. Surgery started with greater omentectomy, left diaphragmatic peritonectomy, and splenectomy. During right diaphragmatic peritonectomy and porta hepatis dissection, we found peri- and retrohepatic implants extending to the left hepatic vein. To remove these difficult-to-reach lesions completely and safely, we performed LLLL using a "predissected" plane along LV. We then resected segment 1 due to bulky disease between it and inferior vena cava (IVC), which provided a direct view of the retrohepatic IVC, allowing for safe tumor removal. After completing CRS in other areas (CC-0), a 90-min HIPEC perfusion (mitomycin-C) was performed. The patient had no major complications. At 24 months post-CRS/HIPEC, he remained symptom- and disease-free.
Removing lesions around the left liver and segment 1 is challenging yet essential to ensure CC in LAMN. While not a routine maneuver, in such cases, LLLL can be utilized to access retrohepatic lesions safely and expeditiously, allowing for their removal.
在肿瘤细胞减灭术（CRS）中实现完全细胞减灭（CC）对于阑尾肿瘤获得良好预后至关重要。然而，当肿瘤生长在肝后左侧间隙并沿静脉韧带（LV）生长时，实现CC极具挑战性，可能需要采取复杂的操作。
本文通过多媒体展示了一位患有低级别阑尾黏液性肿瘤（LAMN）并伴有广泛腹膜播散的患者接受CRS联合左外侧肝叶切除术（LLLL）的分步视频。在初始全身化疗出现毒性且无疾病缓解后，该患者在我们中心寻求CRS及腹腔热灌注化疗（HIPEC）。
术前腹膜癌指数（PCI）为34。手术首先进行大网膜切除术、左侧膈肌腹膜切除术和脾切除术。在右侧膈肌腹膜切除术和肝门解剖过程中，我们发现肝周和肝后种植灶延伸至左肝静脉。为了安全、彻底地切除这些难以触及的病灶，我们沿着LV使用“预分离”平面进行LLLL。由于第1肝段与下腔静脉（IVC）之间存在大量病变，我们随后切除了第1肝段，这使得能够直接观察肝后IVC，从而安全地切除肿瘤。在其他区域完成CRS（CC-0）后，进行了90分钟的HIPEC灌注（丝裂霉素-C）。患者未出现重大并发症。在CRS/HIPEC后24个月，他仍无症状且无疾病复发。
切除左肝及第1肝段周围的病灶具有挑战性，但对于确保LAMN的CC至关重要。虽然这并非常规操作，但在这种情况下，LLLL可用于安全、迅速地处理肝后病灶，从而实现切除。
